An interview with Bogi Eliasen: Part 1

Bogi Eliasen
Director of Health, Copenhagen Institute for Futures Studies

In the first of a two-part interview, we sat down with Bogi Eliasen, a member of the Movement Health Global Board, to talk about the state of health systems today and what he sees as the greatest challenges ahead.

What would you identify as the biggest problems facing global health systems?

We need to be clear what we mean when we ask that question. At the moment, we have a huge focus on ‘health systems’, but the outcome we really want is ‘health’. In other words, not everything related to health is going to be a function of a health system. And the big challenge today is that our health systems are actually ‘sick systems’—rather than optimising health, they focus on delivering solutions to diseases.

Of course, there’s a reason for that. With the development of evidence-based health over the last 150 years, we have hugely increased the average lifespan, which is a great achievement. But as we get older, we become more afflicted with diseases, and that means the global disease burden has greatly increased in the last 30–40 years.

So here’s the question: if you were given the average amount of money spent on a person over a lifespan in any given country, would you spend it as you spent it today? I have asked many people that question and nobody has said yes. 

At the moment, we spend the money very late where we don’t get enough for it. We’re largely focused on acute challenges (such as disease) and not dealing with important non-acute challenges (such as keeping people as healthy as possible through early intervention and prevention).

And why? Because health systems have to work with limited resources and budgets, and a lack of staff means they often have to prioritise urgent care. Until we get a social contract between public and private providers with the goal of optimising health as a whole, it’s going to be really hard to achieve universal coverage.

Which parts of the world are feeling the greatest strain? 

Well, in the poorest parts of the world, most people don't really have meaningful access to health care. They might be able to open a health clinic or hospital door, but that doesn't mean they have access to high-quality care. In the richest parts of the world, on the other hand, the economic sustainability of the ‘sick system’ is starting to break down. 

So these are the two extremes when it comes to different parts of the world. And we need to find a way of working together towards the same ambition: sustainable health systems that aren’t just dealing with acute problems, but are also seen as investments in 'value generators’ for society. It's very hard to have productive societies without health, so we need to get to the stage of seeing individuals as a part of the value of society as a whole. That comes back to ‘sick systems’ vs ‘health systems’—a healthy society in itself reduces the need for very expensive care.

Of course, we will still have care, and obviously people will get some disease burden during their lifetimes. But it’s estimated that a huge portion of what we deal with today is avoidable disease. And once you get one chronic disease, it’s very likely that you will get a second and a third. It’s like a domino effect: for example, obesity leads to type 2 diabetes, high blood pressure, high cholesterol and so on.

So we need to focus on working with the first diagnosis so that you don't enter into the second and the third. That kind of preventative approach would allow us to build more sustainable health systems, so we can help the people who need it the most and move towards the UN’s goal of reducing premature mortality by one third by 2030

What impact has COVID-19 had on health systems?

I think there are many impacts, some of which we will only see in years to come. But one thing that has been highlighted a lot is the need for remote care and digital use. A lot of the necessary technology has been more or less ready for decades, so there’s no reason why we shouldn’t have applied it earlier. Admittedly, many things were rolled out in an emergency, which means that it probably didn't follow the procedures we would normally expect in health care. So it wasn’t entirely a success story.

However, in the long term, COVID was clearly the tipping point in showing that not everything needs to happen in a hospital. Patients don’t necessarily have to spend lots of time visiting doctors or nurses or healthcare professionals—you can do a lot of it from home or in your community.

COVID also showed the value of a strong infrastructure and the ability to work with data and knowledge. In terms of what we call the ‘new biology’, there was a clear difference in how countries could respond. Developing vaccines was one thing, but more developed countries were also able to test for different strains of COVID quickly and easily due to the genomic revolution that we’ve seen the last 30 years, especially with the Human Genome Project. 

So what I foresee coming is the combination of data, digital functions and the new biology. That’s what will help to build the future of health, and when we look back in ten years we’ll be able to see how much COVID actually accelerated that. 

What are the biggest obstacles to reform

Well, health systems need to decide what they actually want to achieve. A lot of the focus today is on building the best possible health system that can deliver the best possible care or service at any given time. But, in reality, the goal is the best average health in the population. Those two things are not aligned. 

As a politician, you respond to acute needs. A sustainable health system is obviously important, but there also needs to be a focus on non-acute needs—so not just buildings or hospitals, but actually getting better health as an outcome. But this is very difficult because no politician wins votes on that. It’s a longer-term goal that stretches across three, four, five or six governments. 

It’s also clear that no one in a political discussion wants to say that we can’t have everything. Ultimately, there are no upper limits on health demands. For example, in the Nordic countries where I live, around 10% of GDP is currently allocated to the health budget, but there's always a demand for more. What’s missing is some imposed limit that encourages innovative solutions: “10% of GDP is what we think is reasonable, so this is what you get. You don't get any more.”

These discussions are necessary, because pouring more money into a broken system doesn't help. One aspect is applying innovations and technologies that already exist but aren’t being used. In other words, how do we move from just focusing on innovation to actually making a difference with innovation, implementation and application? And how do we shift focus from just the ‘what’ to also the ‘how’? We need to get smarter with our spending.

In the second part of this interview, Bogi talks about Movement Health 2030 and the role it can play in dealing with these challenges.